Perioperative Cardiovascular Evaluation and Care for Noncardiac. Dr Mahmoud Ebrahimi Interventional cardiologist 91/9/30

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2 Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery Dr Mahmoud Ebrahimi Interventional cardiologist 91/9/30

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4 Active Cardiac Conditions for Which the Patient Should Undergo Evaluation and Treatment Before Noncardiac Surgery Condition Unstable coronary syndromes Decompensated HF Examples Unstable or severe angina* (CCS class III or IV) Recent MI NYHA functional class IV; Worsening or new-onset HF Significant arrhythmias High-grade atrioventricular block Mobitz II atrioventricular block Third-degree atrioventricular heart block Symptomatic ventricular arrhythmias Supraventricular arrhythmias (including atrial fibrillation) with uncontrolled ventricular rate (HR > 100 bpm at rest) Symptomatic bradycardia Newly recognized ventricular tachycardia Severe valvular disease Severe aortic stenosis (mean pressure gradient greater than 40 mm Hg, aortic valve area less than 1.0 cm2, or symptomatic) Symptomatic mitral stenosis (progressive dyspnea on exertion, exertional presyncope, or HF) May include stable angina in patients who are unusually sedentary. The ACC National Database Library defines recent MI as more than 7 days but within 30 days)

5 Estimated Energy Requirements for Various Activities Can You Can You 1 Met Take care of yourself? 4 Mets Climb a flight of stairs or walk up a hill? Eat, dress, or use the toilet? Walk on level ground at 4 mph (6.4 kph)? Walk indoors around the Do heavy work around the house? house like scrubbing floors or lifting or moving heavy furniture? Walk a block or 2 on level Participate in moderate ground at 2 to 3 mph (3.2 to recreational activities like golf, 4.8 kph)? bowling, dancing, doubles tennis, or throwing a baseball 4 Mets Do light work around the house like dusting or washing dishes? 10 Mets or football? Participate in strenuous sports like swimming, singles tennis, football, basketball, or skiing? MET indicates metabolic equivalent; mph, miles per hour; kph, kilometers per hour. *Modified from Hlatky et al,11 copyright 1989, with permission from Elsevier, and adapted from Fletcher et al.12

6 Cardiac Risk Stratification for Noncardiac Surgical Procedures Risk Stratification Vascular (reported cardiac risk often > 5%) Procedure Examples Aortic and other major vascular surgery Peripheral vascular surgery Intermediate (reported cardiac risk generally 1%-5%) Low (reported cardiac risk generally <1% Intraperitoneal and intrathoracic surgery Carotid endarterectomy Head and neck surgery Orthopedic surgery Prostate surgery Endoscopic procedures Superficial procedure Cataract surgery Breast surgery Ambulatory surgery

7 Recommendations for Preoperative Noninvasive Evaluation of LV Function Class I (none) Class IIa It is reasonable for patients with dyspnea of unknown origin to undergo preoperative evaluation of LV function. (C) It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical status to undergo preoperative evaluation of LV function if not performed within 12 months. (C) Class IIb Reassessment of LV function in clinically stable patients with previously documented cardiomyopathy is not well established. (C) Class III Routine perioperative evaluation of LV function in patients is not recommended. (B)

8 Recommendations for Preoperative Resting 12-Lead ECG Class I: recommended for pts with: At least 1 clinical risk factor* who are undergoing vascular surgical procedures. (B) Known CHD, peripheral arterial disease, or cerebrovascular disease who are undergoing intermediate-risk surgical procedures. (C) Class IIa: reasonable in persons with no clinical risk factors who are undergoing vascular surgical procedures. (B) Class IIb: may be reasonable in patients with at least 1 clinical risk factor who are undergoing intermediate-risk operative procedures. (B) Class III: Preoperative and postoperative resting 12-lead ECGs are not indicated in asymptomatic persons undergoing low-risk surgical procedures. (B) *Clinical risk factors include history of ischemic heart disease, history of compensated or prior HF, history of cerebrovascular disease, DM, and renal insufficiency.

9 Preoperative Coronary Revascularization With CABG or Percutaneous Coronary Intervention in stable cardiac patients

10 Cardiac evaluation and care algorithm for noncardiac surgery

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24 Proposed approach to the management of patients with previous PCI who require noncardiac surgery

25 Treatment for patients requiring PCI who need subsequent surgery

26 Drug Eluting Stents (DES) and Stent Thrombosis premature discontinuation of dual antiplatelet therapy markedly increases the risk of catastrophic stent thrombosis and death or MI. To eliminate the premature discontinuation of thienopyridine: 1. Before implantation of a stent, In patients not expected to comply with 12 months of thienopyridine therapy, whether for economic or other reasons, or are likely to require invasive or surgical procedures within the next 12 months, consideration should be given to implantation of a baremetal stent or performance of balloon angioplasty with provisional stent implantation instead of the routine use of a DES. Grines CL, et al. Circulation. 2007;115:

27 Drug Eluting Stents (DES) and Stent Thrombosis 3. properly and thoroughly patient education about the reasons they are prescribed thienopyridines and the significant risks associated with prematurely discontinuing such therapy. 4. Patients should be specifically instructed before hospital discharge to contact their treating cardiologist before stopping any antiplatelet therapy, even if instructed to stop such therapy by another healthcare provider. 5. Healthcare providers who perform invasive or surgical procedures and who are concerned about periprocedural and postprocedural bleeding must be made aware of the potentially catastrophic risks of premature discontinuation of thienopyridine therapy. Such professionals who perform these procedures should contact the patient s cardiologist if issues regarding the patient s antiplatelet therapy are unclear, to discuss optimal patient management strategy. Grines CL, et al. Circulation. 2007;115:

28 Drug Eluting Stents (DES) and Stent Thrombosis 6. Elective procedures for which there is significant risk of perioperative or postoperative bleeding should be deferred until patients have completed an appropriate course of thienopyridine therapy (12 months after DES implantation if they are not at high risk of bleeding and a minimum of 1 month for bare-metal stent implantation). 7. For patients treated with DES who are to undergo subsequent procedures that mandate discontinuation of thienopyridine therapy, aspirin should be continued if at all possible and the thienopyridine restarted as soon as possible after the procedure because of concerns about late stent thrombosis. Grines CL, et al. Circulation. 2007;115:

29 Recommendations for Beta-Blocker Medical Therapy CLASS I: Beta blockers should be continued 1. in patients undergoing surgery who are receiving beta blockers to treat angina, symptomatic arrhythmias, hypertension, or other ACC/AHA class I guideline indications. (C) 2. patients undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing. (B) CLASS Iia: Beta blockers are probably recommended 1. for patients undergoing vascular surgery in whom preoperative assessment identifies CHD. (B) 2. for patients in whom preoperative assessment for vascular surgery identifies high cardiac risk, as defined by the presence of more than 1 clinical risk factor.* (B) 3. for patients in whom preoperative assessment identifies CHD or high cardiac risk, as defined by the presence of more than 1 clinical risk factor,* who are undergoing intermediate-risk or vascular surgery. (B)

30 Recommendations for Beta-Blocker Medical Therapy CLASS IIb: The usefulness of BB is uncertain 1. In intermediate-risk procedures or vascular surgery, in whom preoperative assessment identifies a single clinical risk factor.* (C) 2. In vascular surgery with no clinical risk factors who are not currently taking beta blockers. (B) CLASS III 1. Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta blockade. (C)

31 Recommendations for Perioperative Beta-Blocker Therapy

32 Recommendations for Statin Therapy CLASS I 1. For patients currently taking statins and scheduled for noncardiac surgery, statins should be continued. (B) CLASS IIa 1. For patients undergoing vascular surgery with or without clinical risk factors, statin use is reasonable. (B) CLASS IIb 1. For patients with at least 1 clinical risk factor who are undergoing intermediate-risk procedures, statins may be considered. (C)

33 Intraoperative and Postoperative Use CLASS IIa of ST-Segment Monitoring can be useful to monitor patients with known CAD or those undergoing vascular surgery, to detect myocardial ischemia during the perioperative period. (B) CLASS IIb may be considered in patients with single or multiple risk factors for CAD who are undergoing noncardiac surgery.(b)

34 CLASS I: troponin measurement for Perioperative MI in patients with ECG changes or chest pain typical of acute coronary syndrome.(c) CLASS IIb:is not well established in patients who are clinically stable and have undergone vascular and intermediate-risk surgery. (C) CLASS III: in asymptomatic stable patients who have undergone low-risk surgery.(c)

35 1. You are asked to evaluate a 55-year-old man with a history of prior myocardial infarction in preparation for an abdominal aortic aneurysm repair. A dobutamine stress echocardiogram has been ordered and shows the following.

36 A 70-year-old man with hypertension and a recently diagnosed solitary pulmonary nodule is scheduled for wedge resection. He is otherwise healthy, active, and regularly plays golf. His ECG reveals left ventricular hypertrophy with secondary repolarization changes consistent with a strain pattern. Your recommendation is a. Stress echocardiography for risk stratification. b. Clear the patient for surgery. c. Coronary angiography. d. Echocardiogram. e. Stress SPECT thallium imaging.

37 An 80-year-old woman with hypertension and a history of congestive heart failure recently suffered a hip fracture and is in need of stabilization. She lives with family but is known to be inactive, primarily because of arthritis. Your recommendation is to do the following: a. Clear the patient for the orthopedic procedure with beta-blocker prophylaxis and careful hemodynamic monitoring. b. Coronary angiography. c. Dobutamine stress echocardiography for risk stratification. d. Echocardiogram, and if left ventricular function is normal, clear the patient for surgery. e. Exercise stress SPECT thallium.

38 A 78-year-old woman with a history of chronic stable angina is scheduled for cataract surgery. Your recommendation is a. Dipyridamole stress SPECT thallium imaging. b. Coronary angiography. c. Clear the patient for cataract surgery. d. Echocardiogram, and if left ventricular function is normal, clear the patient for surgery. e. Exercise stress echocardiography

39 Your patient is a 55-year-old man who is in need of a fem-pop bypass for claudication. What do you recommend for risk stratification? a. Exercise ECG b. Angiography c. Dobutamine stress echocardiography d. Dipyridamole thallium e. Clinical evaluation

40 With best wishes